If you are in an OHP coordinated care organization (CCOA or CCOB), call your CCO. If you are not in a CCOA or CCOB, call providers in your area and ask if they accept OHP (“open card”); or contact a local safety net clinic:

OHP Plus (BMH): For people eligible for Medicaid or the Children's Health Insurance Program (CHIP), such as children, pregnant women, seniors and people with disabilities.

OHP with Limited Drug (BMD, BMM): For people who are eligible for both Medicaid and Medicare Part D.​

Is there a nurse advice line?

Oregon Health Plan Care Coordination - If you are not enrolled in a coordinated care organization for medical care (CCOA or CCOB), you can call 1-800-562-4620 anytime you are sick, hurt or want to talk to a nurse. Additional programs are available for OHP members with more complex conditions. ​

What are OHP pharmacy benefits?

Your doctor will know what prescriptions are covered, and your pharmacy will know whether you will need to pay a copayment.​

OHP Plus (BMH) is the most comprehensive benefit. It covers most health care services. Services to improve vision (e.g., glasses) are covered for children under age 19 and pregnant adults; for non-pregnant adults, vision services are covered only for specific medical conditions.

OHP with Limited Drug (BMD or BMM) covers the same benefits as OHP Plus, except it does not cover drugs that Medicare Part D should cover.

Eye exams for “disorders of refraction and accommodation” are covered for OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage.​

Are glasses or contact lenses covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) only covers glasses or contact lenses to treat the following medical diagnoses:

Pseudoaphakia

Aphakia

Congenital aphakia

Keratoconus

For OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage, only glasses (not contact lenses) are covered for “disorders of refraction and accommodation.”

Will OHP pay for treatment when there is an accident or injury to the eye(s)?

Yes. Urgent/emergent treatment is a covered service for all benefit packages.​

OHP health plans are required to send out a Notice of Action to their members, as defined in OAR 410-141-0260 and 410-141-3263, which includes the denial of payment for services.

All providers should let their patients know whether or not the service is covered before delivering the service, including when services will exceed benefit limits (e.g., more frequent dental care).​

How does the Prioritized List of Health Services determine what OHP covers?

It ranks pairs of health conditions and treatments according to effectiveness. The higher a condition and treatment pair is ranked, the more likely OHP will cover it. To learn more visit our Prioritized List page.​

If OHP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?

All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan.

The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.​

Can a provider represent an OHP member in an appeal regarding the denial of payment for services?

The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.​

Do OHP members have appeal rights when they are disenrolled from an OHP health or dental plan?

Yes. Our rules list the conditions for disenrollment. The plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080 and 410-141-3080).​

Who has to pay copayments?

Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits who are not exempt from copayments. ​

Who does not have to pay copayments?

Children under age 19

Youths in foster care through age 20

Young adults in the Former Foster Care Youth Medical program

Adults who receive OHP Plus (BMH, BMM or BMD) benefits who:

Are pregnant;

Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Aging and People with Disabilities;

Are inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR);

Are American Indian/Alaska Native members of a federally recognized Indian tribe or receive services through a tribal clinic;

Are receiving hospice care; or

Are eligible for the Breast and Cervical Cancer Program.

Do OHP members with other health care coverage have copayments?

Members with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the member for their TPL copayments, coinsurance or deductibles if they are billing OHP for what TPL did not pay.

Providers should only collect the OHP copayment when the amount TPL paid for the service, plus the OHP copayment amount, is less than the amount OHP would normally pay for the service. This means the amount collected may be less than OHP's normal copayment, depending on how much TPL paid. ​

How much are copayments?

OHP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

Table 120-1230-1 in the General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. These include:

Some prescription drugs

Office visits

Home visits

Hospital emergency room services when there is not an emergency

Outpatient hospital services

Outpatient surgery

Outpatient treatment for chemical dependency

Outpatient treatment for mental health

Occupational therapy

Physical therapy

Speech therapy

Restorative dental work

Vision exams​

Which services do NOT have copayments?

Copayments are not charged for:

Emergency services

X-ray and lab services

Durable medical equipment and supplies

Routine immunizations

Drugs ordered through our home-delivery pharmacy program

Family planning services and supplies

Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision.

For members enrolled in an OHP health or dental plan, the services and drugs covered by that plan (copayments can apply to managed care plan services, but most plans have chosen not to charge copayments).

For members with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what OHA would normally pay for the service/drug.

Look at the "Copays?" field on page 2 of your coverage letter. This field will contain a "Yes" for each member of your household who is responsible for copayment, and a “No” for members who are not responsible for copayments. ​

How do I know if a service requires a copayment?

Refer to the OHP Handbook for general descriptions of services requiring copayment. If you believe your health care provider is charging you a copayment in error, contact your OHP health plan or OHP Client Services.​

Are copayments charged per procedure, per visit, per day, etc.?

Providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.​

Who collects the copayment, and when will it be collected?

The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.​

What happens if a member does not pay the copayment?

The member will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.

OHP members who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.​

Can providers refuse to serve OHP members who do not pay a copayment?

No. This does not relieve the member of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.​

Who can OHP members call with questions about their copayment requirements?

They can call the Client Services Unit, 1-800-273-0557. They can also call their caseworker.​

What can OHP members do if they feel they should not have to pay a copayment?

They may ask for a hearing if they think a provider made a mistake in the amount charged. They may also ask for a hearing if they think DHS made a mistake in their eligibility that has caused them to be subject to copayment requirements when they should not be subject.​

What can Client Services help me with?

Describe the types of medical and dental care OHP covers.

Coach members on what to do when they have problems getting medical, dental or mental health care.

Follow up on member complaints about services OHP has determined are not covered.

Refer OHP health plan members to their plan's customer service when appropriate.

Advise OHP members on the process for the review and resolution of health care bills.

Answer basic questions about dates of OHP eligibility and other related issues.

Issue Certificates of Creditable Coverage requested by members leaving OHP and moving to commercial health insurance. Requests are mailed directly to commercial health insurance providers OR the adult representative on the OHP record.

Process requests from OHP members in the Pharmacy Management Program who want to change their assigned pharmacy. ​

What can Client Services NOT help me with?

Refer clients to specific doctors, dentists, clinics or other available providers. View our Access to Care questions to learn how to find an OHP health care provider.

Determine what specific health care services are covered or not covered for any specific client. OHP coverage depends on the client's benefit package and the health care condition(s) the service is supposed to treat. Contact your health care provider.

Change a client's record (for example, add family members to cases, change address). Contact your caseworker.​

Where can I find the drugs covered by OHP health plans?

You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). ​

​

Where can I find information about Medicare Part D coverage?

Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.​

What happens when a change occurs in an OHP member’s household (e.g., pregnancy, household members moving in or out, change in income)?

All OHP members must report household changes to their worker.

The changes may make the member ineligible for medical assistance, or make the member eligible under a different benefit package.

If the reported changes affect medical eligibility, the member will receive a letter telling how eligibility has changed.

​​

How do I get forms in alternate formats, such as Braille?

If you need a form or publication in a different format, such as (but not limited to) Braille, large print, audio tape, computer disk (in ASCII format) or oral presentation, contact your worker.​

If you still need help after contacting your plan and the provider who is billing you, send a copy of the bill to:

OHP Client Services 500 Summer St. NE, E44 Salem, OR 97301​

What is the Preferred Drug List (PDL)?

During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members. This list is called the Preferred Drug List (PDL).

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Why do we have a PDL?

The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included. ​

How do I use the PDL?

The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. OHA asks that when practitioners start a new drug, to consider the drugs on the PDL first. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL (PDF) or use the Searchable PDL. The Searchable PDL is an interactive database that includes preferred/non-preferred status, copayment information and prior authorization criteria, if applicable, for all active rebateable drugs.​

Any time we want to change what OHP covers or whom OHP serves, OHA must ask the federal Centers for Medicare and Medicaid Services (CMS) to approve the change. Sign up for OHP Public Notices and Meetings to find out when we have sent such a request to CMS.

We send OHP provider announcements to inform affected providers about changes to our fee-for-service payment rates. Sign up for OHP Provider Announcements to get these notifications.​

What are public meetings?

According to Oregon law, any meeting related to medical assistance is a public meeting. The division holds the following meetings and posts them on the OHP Public Meetings Calendar:

A transportation brokerage is a local government entity that contracts with the Oregon Health Authority to provide non-emergent transportation services to Oregon Health Plan (OHP) clients who receive OHP Plus (BMM, BMH, BMD, CWX) benefits.​

Can you arrange transportation outside the brokerage (i.e., directly with a preferred transportation provider)?

No. All medical ride requests must go through the brokerage.

The rides must be authorized and assigned to a brokerage sub-contracted provider that meet the client’s needs most appropriately and are the lowest cost.

If a facility or branch arranges transportation without the broker's authorization, the transportation provider will not be paid through Medicaid.

When the brokerage is closed, clients should call the brokerage’s after-hours number if a ride is needed for an urgent medical issue.

Does the brokerage call center offer any choices when it sets up rides?

The brokerage or call center staff must meet two main criteria:

Find the most appropriate ride for the client based on actual need, not want.

Find the ride that is the lowest cost.

Oregon's federal waiver and current federal law allow the state to limit a client's freedom of choice with NEMT. Freedom of choice, in this context, refers to the general right a Medicaid participant has to choose service providers.

What questions do brokerages ask when an OHP member calls for a ride?

The brokerage will check the eligibility of the person, verify if the ride is to a Medicaid-covered service, and assess the client’s ability and needs. These questions are requirements brokerages ask to meet Medicaid standards:

Where do you want to go?

Are you going to an OHP-covered health care service? (If a client is unsure whether the service is covered, and it is unclear whether the service is a covered service, the brokerage will follow up with the provider.)

Do you have any other means of transportation?

Do you have any special needs?​

​

OHP members at residential facilities expect to be helped (from their room, into the van, into the doctor’s office, etc.). Who provides this level of service?

The drivers are there to drive. If a client needs a care attendant, it is the facility's or the client's responsibility to provide one.

The brokerage contract does not allow drivers to enter clients' rooms or escort clients to their appointments. Clients will need to be ready at the front door of the pick-up address. ​

Some OHP clients have limited mobility; will the driver assist them with getting onto the van?

Yes, ride requests should identify their special needs, so the drivers will know to provide assistance boarding and de-boarding the vehicle.​

Will the brokerages transport children less than 12 years old unescorted?

No, the brokerage will not transport children less than 12 years old unescorted.

The exception is when a Department of Human Services (DHS) volunteer is available to drive the child, primarily because of protocols established by the DHS Child Welfare program and because of liability issues.

What would happen if the hospital needs to discharge a patient at 9:30 p.m.?

Brokerages have their own processes and protocols for after-hours transportation that allow for the transport to take place with authorization to follow.

Hospitals should follow the after hours procedure for the brokerage and contact the appropriate after hours providers. Ambulance providers should not be used unless an ambulance is the appropriate mode for the client.

Can anyone ride with the client to their appointment?

If
the client has a medical need to have an attendant travel with them, or the
client is less than 12 years old, one attendant is allowed to accompany the
client on the transport.

Otherwise,
whether or not an extra person can ride along on the transport depends on
whether the transportation provider agrees to allow the extra person at no
additional cost.

In addition, this must be negotiated with the brokerage call
center, and is subject to available space.

What would happen if all of the transportation providers refused to give an OHP member a ride due to scheduling conflicts?

The brokerage would ask the provider whether the appointment could be re-scheduled or delayed without doing harm to the client. If not, the brokerage would secure a provider from a different service level or from outside of the region. The client would be given options.

​

If a provider gets a call after hours directly from a client asking for a ride, how does the provider know they'll get paid if they provide the ride?

Providers take a risk when they accept this type of ride. They can ask to see the client’s medical card or call the toll-free number for the Automated Voice Response​ (AVR) to see if the person is eligible for services.

What is a client "no-show"?

If a client has a scheduled ride and is not at the pick-up location as arranged, the driver will report a "no-show" to the brokerage.

Clients cannot be billed, and the brokerage cannot pay providers for these trips.

If a client needs to cancel a ride, the client should call the brokerage.

Repeated “no-shows” may result in requiring the client to phone in to confirm rides before pick up, schedule no more than one ride at a time, travel with a specific provider, or travel with an escort.

The “no-show” policy holds clients accountable for using their ride benefits appropriately.​

Do the brokerages fulfill same-day ride requests?

The broker will try to arrange for same-day rides; however, it will depend on whether there is a provider available and whether prior authorization can be completed.

What if clients have complaints about a certain driver or transportation service?

The most direct way to process concerns and complaints is to share them with the brokerage.

After the complaint is researched, the brokerage may sanction or terminate a provider which is unable to provide on-time, safe services.​

What is home-delivery pharmacy?

Home-delivery pharmacy allows you to order a three-month supply of covered drugs or diabetic supplies and have it mailed to you each month, either to a residential address, PO Box or clinic.

If you have OHP benefits, you pay nothing for your home-delivered prescriptions. There are no copayments and no shipping fees.​

Who can use home-delivery pharmacy?

Clients with ongoing prescriptions for drugs that OHP covers on a fee-for-service basis. These include:

Clients not enrolled in an OHP medical plan;

OHP medical plan members (CCOA and CCOB) with ongoing prescriptions for drugs not covered by the plan, such as most mental health drugs;

Clients with OHP with Limited Drug benefits with ongoing prescriptions for drugs covered by OHP, but not Medicare, such as certain decongestants.

Home delivery isn't for everyone. You may prefer to talk to a pharmacist in person about new medications.

How long does home-delivery pharmacy take to fill prescriptions?

If you need the medicine right away, you should visit a local pharmacy.

It takes up to 10 days for your prescriptions to be delivered by mail. If you and your doctor are trying out different drugs, you should wait until you find the ones you will take long-term before you use home-delivery. ​

What prescriptions can the home-delivery pharmacy fill?

This service is for ongoing monthly prescriptions for drugs and diabetic supplies covered by OHP on a fee-for-service (“open card”) basis. Such prescriptions include:

Prescriptions for clients not enrolled in an OHP medical plan

Prescriptions for mental health drugs (which are generally paid by OHA, not the OHP medical plan)

Prescriptions for certain drugs covered by OHP, but not covered by Medicare (such as certain decongestants).

​

How do I get started using home-delivery pharmacy?

You or your prescribing provider can start the process. Be sure to have the prescription number and your Oregon Health ID number handy.

Allow 8-10 days between ordering and delivery of your medications.

When it's time for a refill, you will get a reminder in the mail. Make sure to place refill orders about 14 days before your current supply runs out.

Call 1-877-935-5797 (Monday through Friday, from 8 a.m. to 5 p.m.)

You can also call to transfer existing prescriptions from a local pharmacy or another home-delivery pharmacy.​

How do I mail or fax a home-delivery prescription order?

Fill out the order form (English or Spanish) and send with the prescription to:

Wellpartner Inc.PO Box 5909Portland, OR 97228-5909

Fax 1-866-624-5797

Missing or incomplete information on your order will delay processing.

Where can I learn more about home-delivery pharmacy?

If you are not in an OHP coordinated care organziation (CCOA or CCOB), see the Wellpartner website.

If you are in a CCOA or CCOB, ask your CCO if they provide home-delivery pharmacy service.

Verifying that the client does not have other means to get to the appointment, and

Authorizing the most appropriate type of transportation service based on the client’s needs.

​

Who provides the actual rides for the clients?

The brokerage sub-contracts with drivers and transportation providers to provide rides they have arranged.​

What type of authorization is necessary for NEMT?

Requests for NEMT must be prior authorized. This includes requests for rides or reimbursement of transportation expenses such as mileage, meals and lodging. ​

When lodging and meal expenses arise from an emergency situation, are lodging and meals considered NEMT expenses or something else? Who is responsible for authorizing and reimbursing them?

In this kind of situation (for example, when an emergency ambulance takes a child and parent to Doernbecher Children’s Hospital, and the parent qualifies as a medically necessary attendant whose expenses are allowable under the NEMT program), only the ride is considered an emergency expense.

Any other allowable travel expenses would be considered NEMT expenses, and the client or their representative must contact the brokerage as soon as possible within 30 days of the transport for authorizing and reimbursement of these expenses.​

Can a transportation brokerage reimburse overnight lodging and meals for an attendant who stays with the client when the client is admitted as in inpatient to a hospital?

No. Once a client is admitted as an inpatient, NEMT benefits can no longer pay for an attendant because the medical facility provides all of the client’s care. There are some exceptions:

If the doctor says in writing that the attendant is medically necessary, or

If it is less expensive to pay for the attendant’s meals and lodging than to return the attendant home and bring the attendant back again when the client is released.​

Who authorizes reimbursement for medical-related lodging and meals?

Brokerages now authorize and reimburse clients for medical-related lodging and meals in all counties.

Rules allow reimbursements to clients for expenses less than $10 to be held until they reach the $10 amount, but may reimbursements be processed for less than$10?

Yes. The $10 threshold exists to avoid writing checks for very small amounts, but reimbursements can be processed for less than $10 if the brokerage allows.

Can clients get rides to any provider they want to go to for Medicaid-covered services?

​No, rides are only covered to the providers in the client’s local area, unless there is no provider available in the local area.

Brokerages will seek guidance from the client’s primary care or referring provider.

Although clients may choose to go out of their local area to any provider that will accept Medicaid, the transportation may not be covered if there is an appropriate local area provider available.​

Is there a time limit on how long a client must wait if they are in a grouped ride?

​Wait times on shared rides are reviewed individually and factor in client needs​.

Can NEMT be used to shop for a new care facility, or relocate to another care facility or out of state?

​NEMT can only cover moves to a new care facility for clients who have had a change in condition, noted in their DHS care plan, resulting in a need for a new service setting with a higher or lower level of care.

NEMT cannot cover shopping for another facility, moving to another facility of the same level of care or moving out of state.

DHS has some non-medical funds that may be available for some of these moves. Clients should talk with their local case workers to find out what may be available to them.

How should an ambulance company bill ambulance services when medical personnel determine it was not an emergency?

​It should be billed as a non-emergent ambulance service if the ride was provided or as an aid call if the ambulance personnel do not transport the client. This is an exception to the guidance that brokerages authorize non-emergent ambulance trips.​

What is the brokerage’s responsibility regarding non-emergent ambulance trips?

Questions about copayments

Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits who are not exempt from copayments. ​

Who does not have to pay copayments?

Children under age 19

Youths in foster care through age 20

Young adults in the Former Foster Care Youth Medical program

Adults who receive OHP Plus (BMH, BMM or BMD) benefits who:

Are pregnant;

Receive services under a home- and community-based waiver: These services include most in-home services or services in an adult foster home or other home or facility paid by Aging and People with Disabilities;

Are inpatients in a hospital, nursing facility, or Intermediate Care Facility for the Mentally Retarded (ICF/MR);

Are American Indian/Alaska Native members of a federally recognized Indian tribe or receive services through a tribal clinic;

Are receiving hospice care; or

Are eligible for the Breast and Cervical Cancer Program.

Do OHP members with other health care coverage have copayments?

Members with both Medicare and Medicaid coverage have copayments for the applicable Medicaid services. Providers cannot charge the member for their TPL copayments, coinsurance or deductibles if they are billing OHP for what TPL did not pay.

Providers should only collect the OHP copayment when the amount TPL paid for the service, plus the OHP copayment amount, is less than the amount OHP would normally pay for the service. This means the amount collected may be less than OHP's normal copayment, depending on how much TPL paid. ​

How much are copayments?

OHP charges a $3 copayment for certain types of outpatient services, and a $1 or $3 copayment for certain prescription drugs. The copayment amount depends on the type of prescription filled:

Table 120-1230-1 in the General Rules administrative rulebook lists the provider types and services subject to OHP Plus copayments. These include:

Some prescription drugs

Office visits

Home visits

Hospital emergency room services when there is not an emergency

Outpatient hospital services

Outpatient surgery

Outpatient treatment for chemical dependency

Outpatient treatment for mental health

Occupational therapy

Physical therapy

Speech therapy

Restorative dental work

Vision exams​

Which services do NOT have copayments?

Copayments are not charged for:

Emergency services

X-ray and lab services

Durable medical equipment and supplies

Routine immunizations

Drugs ordered through our home-delivery pharmacy program

Family planning services and supplies

Diagnostic and preventive dental services – These include oral examinations to identify changes in your health or dental status. They also include routine cleanings, x-rays, lab work and tests needed to make a diagnosis or treatment decision.

For members enrolled in an OHP health or dental plan, the services and drugs covered by that plan (copayments can apply to managed care plan services, but most plans have chosen not to charge copayments).

For members with Medicare and other health coverage resources (third-party liability, or TPL), any services and drugs paid by the TPL where the TPL's payment is as much or more than what OHA would normally pay for the service/drug.

Copayment amounts ($1 or $3) will only display for members responsible for copayment. If an OHP member is exempt from copayment, the copayment will read $0.00 for all services. ​

How do I know if someone should pay a copayment?

Look at the "Copays?" field on page 2 of your coverage letter. This field will contain a "Yes" for each member of your household who is responsible for copayment, and a “No” for members who are not responsible for copayments. ​

If a service requires copayment, the service will list the amount to pay ($1, or $3). Services that do not require copayment will list $0. Table 120-1230-1 in the General Rules also lists the services that require copayment and the amounts that apply. ​

How do I know if a service requires a copayment?

Refer to the OHP Handbook for general descriptions of services requiring copayment. If you believe your health care provider is charging you a copayment in error, contact your OHP health plan or OHP Client Services.​

Are copayments charged per procedure, per visit, per day, etc.?

Providers may charge the applicable copayment per visit per day. Pharmacies may charge for each fill.​

Who collects the copayment, and when will it be collected?

The health care provider or pharmacy collects the copayment. They may collect it at the time of service or during the regular billing cycle.​

What happens if a member does not pay the copayment?

The member will still be able to receive the health care service or drug; however, the provider can choose whether to collect it at a later time.

OHP members who do not pay the copayment should see the provider's billing clerk to discuss the situation and options. Only the provider can waive the copayment. However, the provider may also turn the debt over to a collection agency.​

Can providers refuse to serve OHP members who do not pay a copayment?

No. This does not relieve the member of the responsibility to pay and it does not stop the provider from attempting to collect the copayments. The copayment is a legal debt, and is due and payable to the provider.​

Who can OHP members call with questions about their copayment requirements?

They can call the Client Services Unit, 1-800-273-0557. They can also call their caseworker.​

How does OHA account for OHP copayments?

We compute the total OHP copayment due for services billed. We pay the total allowable amount, minus the correct copayments and any third-party payments. Our explanation of benefits (EOB) identifies copayment deductions. ​

What can OHP members do if they feel they should not have to pay a copayment?

They may ask for a hearing if they think a provider made a mistake in the amount charged. They may also ask for a hearing if they think DHS made a mistake in their eligibility that has caused them to be subject to copayment requirements when they should not be subject.​

Are FQHCs and RHCs required to charge copayments to OHP health plan members?

For all OHP members, OHA pays for covered mental health drugs on a fee-for-service basis.

For the purposes of the above payment policy, "mental health drugs" are defined as those drugs classified by First DataBank in the Standard Therapeutic Class equal to Class 07 (Ataractics, Tranquilizers), Class 11 (Psychostimulants, Antidepressants).

In addition, lamotrigine and divalproate are also considered mental health drugs.

Or call the Oregon Pharmacy Call Center at 888-202-2126 with the diagnosis code and your NPI.

​

Where can I find the drugs covered by OHP health plans?

You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). ​

​

Where can I find information about Medicare Part D coverage?

Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.​

What is the Preferred Drug List (PDL)?

During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members. This list is called the Preferred Drug List (PDL).

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Why do we have a PDL?

The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included. ​

How do I use the PDL?

The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. OHA asks that when practitioners start a new drug, to consider the drugs on the PDL first. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL (PDF) or use the Searchable PDL. The Searchable PDL is an interactive database that includes preferred/non-preferred status, copayment information and prior authorization criteria, if applicable, for all active rebateable drugs.​

Home-delivery pharmacy allows you to order a three-month supply of covered drugs or diabetic supplies and have it mailed to you each month, either to a residential address, PO Box or clinic.

If you have OHP benefits, you pay nothing for your home-delivered prescriptions. There are no copayments and no shipping fees.​

Who can use home-delivery pharmacy?

Clients with ongoing prescriptions for drugs that OHP covers on a fee-for-service basis. These include:

Clients not enrolled in an OHP medical plan;

OHP medical plan members (CCOA and CCOB) with ongoing prescriptions for drugs not covered by the plan, such as most mental health drugs;

Clients with OHP with Limited Drug benefits with ongoing prescriptions for drugs covered by OHP, but not Medicare, such as certain decongestants.

Home delivery isn't for everyone. You may prefer to talk to a pharmacist in person about new medications.

How long does home-delivery pharmacy take to fill prescriptions?

If you need the medicine right away, you should visit a local pharmacy.

It takes up to 10 days for your prescriptions to be delivered by mail. If you and your doctor are trying out different drugs, you should wait until you find the ones you will take long-term before you use home-delivery. ​

What prescriptions can the home-delivery pharmacy fill?

This service is for ongoing monthly prescriptions for drugs and diabetic supplies covered by OHP on a fee-for-service (“open card”) basis. Such prescriptions include:

Prescriptions for clients not enrolled in an OHP medical plan

Prescriptions for mental health drugs (which are generally paid by OHA, not the OHP medical plan)

Prescriptions for certain drugs covered by OHP, but not covered by Medicare (such as certain decongestants).

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How do I get started using home-delivery pharmacy?

You or your prescribing provider can start the process. Be sure to have the prescription number and your Oregon Health ID number handy.

Allow 8-10 days between ordering and delivery of your medications.

When it's time for a refill, you will get a reminder in the mail. Make sure to place refill orders about 14 days before your current supply runs out.

Call 1-877-935-5797 (Monday through Friday, from 8 a.m. to 5 p.m.)

You can also call to transfer existing prescriptions from a local pharmacy or another home-delivery pharmacy.​

How do I mail or fax a home-delivery prescription order?

Fill out the order form (English or Spanish) and send with the prescription to:

Wellpartner Inc.PO Box 5909Portland, OR 97228-5909

Fax 1-866-624-5797

Missing or incomplete information on your order will delay processing.

Where can I learn more about home-delivery pharmacy?

If you are not in an OHP coordinated care organziation (CCOA or CCOB), see the Wellpartner website.

If you are in a CCOA or CCOB, ask your CCO if they provide home-delivery pharmacy service.

Questions about benefit coverage

Oregon Health Plan Care Coordination - If you are not enrolled in a coordinated care organization for medical care (CCOA or CCOB), you can call 1-800-562-4620 anytime you are sick, hurt or want to talk to a nurse. Additional programs are available for OHP members with more complex conditions. ​

What are OHP pharmacy benefits?

Your doctor will know what prescriptions are covered, and your pharmacy will know whether you will need to pay a copayment.​

OHP Plus (BMH) is the most comprehensive benefit. It covers most health care services. Services to improve vision (e.g., glasses) are covered for children under age 19 and pregnant adults; for non-pregnant adults, vision services are covered only for specific medical conditions.

OHP with Limited Drug (BMD or BMM) covers the same benefits as OHP Plus, except it does not cover drugs that Medicare Part D should cover.

Eye exams for “disorders of refraction and accommodation” are covered for OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage.​

Are glasses or contact lenses covered?

For non-pregnant adults age 21 or older, OHP Plus (BMM, BMH and BMD) only covers glasses or contact lenses to treat the following medical diagnoses:

Pseudoaphakia

Aphakia

Congenital aphakia

Keratoconus

For OHP members under age 21 with BMM, BMH and BMD benefit coverage, and for pregnant OHP members with BMP or CWX benefit coverage, only glasses (not contact lenses) are covered for “disorders of refraction and accommodation.”

Will OHP pay for treatment when there is an accident or injury to the eye(s)?

Yes. Urgent/emergent treatment is a covered service for all benefit packages.​

If an OHP member wants a service that is not covered by their benefit package or is not covered for the condition being treated, the member must sign an Agreement to Pay form that contains all the elements of the OHP 3165 form, as required by OAR 410-120-1280. This form shows that the OHP member understands the service is not covered and agrees to pay for the service.

Without this form, providers may be responsible for costs related to providing excluded and limited services.​

How do OHP members know if a health care service isn't covered?

OHP health plans are required to send out a Notice of Action to their members, as defined in OAR 410-141-0260 and 410-141-3263, which includes the denial of payment for services.

All providers should let their patients know whether or not the service is covered before delivering the service, including when services will exceed benefit limits (e.g., more frequent dental care).​

How does the Prioritized List of Health Services determine what OHP covers?

It ranks pairs of health conditions and treatments according to effectiveness. The higher a condition and treatment pair is ranked, the more likely OHP will cover it. To learn more visit our Prioritized List page.​

Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL.

The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum.

The HRC submitted recommendations to the division for pricing and the division made cost-effective selections, creating the PDL. ​

Where can I find the Preferred Drug List (PDL)?

You can view the current PDL (PDF) or use the Searchable PDL. The Searchable PDL is an interactive database that includes preferred/non-preferred status, copayment information and prior authorization criteria, if applicable, for all active rebateable drugs.​

Questions about complaints and appeals

If OHP or the plan denies coverage of a service that has already been delivered, can an OHP member appeal the denial?

All OHP members can file a request for hearing if they disagree with a payment decision. Members of OHP health or dental plans who disagree with the plan’s denial of payment can also appeal the decision with their plan.

The OHP member is only responsible for payment if he or she signed a waiver agreeing to be responsible for payment of the non-covered service.​

Can a provider represent an OHP member in an appeal regarding the denial of payment for services?

The OHP member can designate anyone as his or her representative in an appeal or hearing. The member must provide written consent.​

Are there federal rules about a Medicaid client's right to a hearing?

Yes. The Code of Federal Regulations (CFR) governs hearing rights. 42 CFR 431.220(b) says we need not grant a hearing when the only issue is a federal or state law that requires an automatic change that adversely affects some or all recipients.​

Do OHP members have appeal rights when they are disenrolled from an OHP health or dental plan?

Yes. Our rules list the conditions for disenrollment. The plan must meet those conditions before we will approve the request for disenrollment. (See OAR 410-141-0080 and 410-141-3080).​

I disagree with a payment decision made by OHA or an OHP health plan. What can I do?

You can request a provider appeal. The General Rules outline your options and how to use them.

Claim re-determination – Request to OHA to review your claim due to a technical error.